Provider Demographics
NPI:1083032999
Name:MARTIN, GERARDO (RPH)
Entity Type:Individual
Prefix:MR
First Name:GERARDO
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HIGHWAY 274
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-6045
Mailing Address - Country:US
Mailing Address - Phone:803-619-7028
Mailing Address - Fax:
Practice Address - Street 1:175 HIGHWAY 274
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-6045
Practice Address - Country:US
Practice Address - Phone:803-619-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-29
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist